Multilevel examination of diabetes in modernising China: what elements of urbanisation are most associated with diabetes?

Diabetologia. 2012 Dec;55(12):3182-92. doi: 10.1007/s00125-012-2697-8. Epub 2012 Aug 26.


Aims/hypothesis: The purpose of this study was to examine the association between urbanisation-related factors and diabetes prevalence in China.

Methods: Anthropometry, fasting blood glucose (FBG) and community-level data were collected for 7,741 adults (18-90 years) across 217 communities and nine provinces in the 2009 China Health and Nutrition Survey to examine diabetes (FBG ≥7.0 mmol/l or doctor diagnosis). Sex-stratified multilevel models, clustered at the community and province levels and controlling for individual-level age and household income were used to examine the association between diabetes and: (1) a multicomponent urbanisation measure reflecting overall modernisation and (2) 12 separate components of urbanisation (e.g., population density, employment, markets, infrastructure and social factors).

Results: Prevalent diabetes was higher in more-urbanised (men 12%; women 9%) vs less-urbanised (men 6%; women 5%) areas. In sex-stratified multilevel models adjusting for residential community and province, age and household income, there was a twofold higher diabetes prevalence in urban vs rural areas (men OR 2.02, 95% CI 1.47, 2.78; women, OR 1.94, 95% CI 1.35, 2.79). All urbanisation components were positively associated with diabetes, with variation across components (e.g. men, economic and income diversity, OR 1.42, 95% CI 1.20, 1.66; women, transportation infrastructure, OR 1.18, 95% CI 1.06, 1.32). Community-level variation in diabetes was comparatively greater for women (intraclass correlation [ICC] 0.03-0.05) vs men (ICC ≤0.01); province-level variation was greater for men (men 0.03-0.04; women 0.02).

Conclusions/interpretation: Diabetes prevention and treatment efforts are needed particularly in urbanised areas of China. Community economic factors, modern markets, communications and transportation infrastructure might present opportunities for such efforts.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Blood Glucose / metabolism*
  • Body Mass Index
  • China / epidemiology
  • Diabetes Mellitus, Type 2 / blood*
  • Diabetes Mellitus, Type 2 / epidemiology*
  • Diabetes Mellitus, Type 2 / prevention & control
  • Educational Status
  • Female
  • Glycated Hemoglobin / metabolism*
  • Health Surveys
  • Humans
  • Male
  • Middle Aged
  • Nutritional Status
  • Prevalence
  • Public Health
  • Sex Distribution
  • Socioeconomic Factors
  • Surveys and Questionnaires
  • Urban Population / statistics & numerical data*
  • Urbanization*


  • Blood Glucose
  • Glycated Hemoglobin A
  • hemoglobin A1c protein, human